A Reappraisal of the Inverse Care Law

A Reappraisal of the Inverse Care Law by Kerris Cooper Durham University 2010


In a time when the Health Gap continues to widen, health care services are crucial in tackling inequalities. However, studies such as the Black Report suggest the NHS is not delivering an equitable service, despite equity being one of its founding principles; access, utilisation and quality of care received appears to vary according to socioeconomic class. Not only is the NHS not alleviating the problem of the Health Gap, but in providing an inequitable service it appears to be contributing to the problem it was established to resolve.

This apparently negative relationship between socioeconomic class and care received was conceptualised by Julian Tudor-Hart as the ‘Inverse Care Law’ in 1971. This project is a reappraisal of Hart’s original theory. Following a review of the literature which suggests that the Inverse Care Law still exists, it is proposed that its source actually lies in an individual’s socioeconomic class and the effect this has on the interpersonal relations between GPs and patients, rather than in the economic context that the health service is situated in as Hart originally stated. This theory is tested by analysing The National Survey of Local Health Services (2006) using SPSS software and comparing the relationship between individual socioeconomic status and deprivation level of Primary Care Trust (PCT) area with indicators of quality of healthcare received. Age was also considered as a control variable.

Results showed relationships opposite to those expected for both socioeconomic status and age: patients who were younger or of a higher socioeconomic class were more likely to rate services negatively. Age also appeared to be a more significant factor than socioeconomic status. Conversely the deprivation level of PCTs showed a weak relationship in line with Hart’s own theory: those from more deprived PCT areas were more likely to rate their experiences of health services negatively.

Two explanations for these results were considered: i) that those of a lower socioeconomic class and younger age genuinely receive a better service or ii) that the role of expectations may be obscuring actual differences in experience of healthcare. Evidence was found in support that people of a higher social class and of a younger age generally have higher expectations of health services and are therefore more likely to be critical of them. This is particularly true of higher resource groups in deprived areas, which also fits with the results of PCT areas. It is concluded that to account for the role of expectations, further research needs to be done that is not self-reported from patients. Whilst this study has not found conclusions to its original aims, (to locate the source of the Inverse Care Law), it has identified the potentially important role of expectations in assessments of health care services and that more research needs to be done in this area. It also suggests that more consideration ought to be given to age which appears to be more significant than socioeconomic class. That there is still a difference between high and low deprivation PCT areas only reinforces the relevance of this project and testifies to the continued existence of the Inverse Care Law, despite recent health care policies.


Chapter 1: Introduction

Chapter 2: Literature Review

  • What is the Inverse Care Law.
  • The Inverse Care Law and Waiting Time and Classification
  • Type for Cardiac Surgery
  • The Inverse Care Law and the Diagnosis and Treatment of Depression in Primary Care
  • The Inverse Care Law and the Availability of Health Promotion Clinics
  • The Inverse Care Law in Clinical Primary Care
  • Evidence Against the Inverse Care Law in Provision of Care for Coronary Heart Disease
  • Summary of the Studies and Literature
  • Implications for Further Research

Chapter 3: Methodology

  • Design
  • Participants
  • Materials
  • Procedure
  • Limitations
  • Ethics

Chapter 4: Analysis of Results

Chapter 5: Discussion

  • Results Summary.
  • Results in Relation to Literature Review
  • The Role of Expectations
  • Implications for Research and Policy

Chapter 6: Conclusion and Bibliography